Osteoporosis: Which Current Treatments Reduce Fracture Risk?

Risk factors for osteoporosis include advanced age, corticosteroid use, cigarette smoking, family history, thin body habitus, and of particular importance, previous fractures. I urge you to consider treatment for any woman who has had an osteoporotic fracture: in the MORE study,(2) 20% of the patients in the placebo group who had a previous vertebral fracture had another vertebral fracture within 36 months, even though they were taking calcium and vitamin D supplements.

Preventing and Treating Osteoporosis
Drugs approved by the Food and Drug Administration for preventing osteoporosis are estrogen, raloxifene (a selective estrogen receptor modulator, or SERM), and alendronate and risedronate (bisphosphonates); those approved for treating osteoporosis are calcitonin, raloxifene, alendronate, and risedronate. An essential part of the regimen with any of these agents is an adequate intake of calcium and vitamin D.

Calcium and vitamin D
Although calcium and vitamin D are frequently given to osteoporotic patients, no study has shown conclusively that they reduce fracture risk by themselves. Studies that did demonstrate an effect (3,4) may have been confounded by the presence of vitamin D insufficiency.

Still, optimizing calcium and vitamin D intake through diet or supplementation is the basis for prevention and treatment of osteoporosis. It may help to think of calcium and vitamin D as the cement powder we may use to set a fence post. The only way the cement powder will hold the post is if we add water. In osteoporosis, calcium and vitamin D are like cement powder, and the drugs that have been approved are the water.

Calcium supplements should provide 500 to 1,000 mg of elemental calcium per day, either as calcium carbonate (eg, Os-Cal, Tums, taken with food) or calcium citrate (eg, Citracal, taken without regard to food). Vitamin D supplements should provide 400 to 800 units/day.

Estrogen replacement therapy
Most of the data on the efficacy of estrogen in osteoporosis are from case-control and cohort studies, (5,6) in which women taking estrogen had a 20% to 60% lower incidence of hip fractures and a 50% lower incidence of spine fractures than did women not taking estrogen. A major drawback of these studies is that they were not randomized: patients self-selected estrogen therapy.

One small prospective study (7) evaluated the effect of transdermal estrogen on spine fracture reduction in 75 women with osteoporosis. Estrogen significantly reduced the number of new spine fractures, but the number of patients who had fractures was not statistically different between the active treatment group and the placebo group. A large prospective, randomized study sponsored by the National Institutes of Health is underway to determine the effects of estrogen on the bones, heart, and breasts.

A variety of preparations is available. A typical regimen is conjugated equine estrogen (Premarin) 0.625 mg/day. In women with a uterus, medroxyprogesterone acetate (eg, Provera, Cycrin, Amen) 5 to 10 mg is also taken on the first 12 days of the month.

Reprinted from the Cleveland Clinic Journal of Medicine, Volume 67, Number 10, October 2000, Pages 701-703.

Disclosure: Dr. Baran is a consultant with Merck and Procter & Gamble and is a member of the speakers bureaus of Merck, Procter & Gamble, and Wyeth.

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